Allegheny College Employee Benefits Enrollment Guide

Transcription

1 Allegheny College Employee Benefits Enrollment Guide PLAN YEAR JULY 1, 2014 JUNE 30, 2015

2 Welcome to Open Enrollment Open enrollment for the 2014/15 medical, dental or vision plans is officially open. Now is the time to enroll, change, or cancel coverage in the medical, dental or vision plans for changes to be effective July 1, You will be able to enroll, change or cancel coverage in any of the plans. Open enrollment is from April 1, 2014 April 30, There has been no change to the vision rates, and an additional two-year rate guarantee was approved. The dental rates have been reduced by 3.5% with a two-year rate guarantee. Attached you will find the rates for the dental and vision plans effective July 1, If you are interested in enrolling, changing or canceling coverage in either plan, please complete the payroll authorization form on page 13 and the appropriate dental and/or vision enrollment/change form on pages 16 and 18. The medical rates and employee contributions are also attached for your reference. You will only need to complete a new enrollment form (page 15) for either the PPO or the QHDHP Plans if you plan to cancel or change your level of coverage. Otherwise, you will not need to complete a new enrollment form for either medical plan. All employees will need to complete the Payroll Authorization form for medical coverage enrollment on page 11. You will also need to complete the HSA Enrollment form for the QHDHP on page 12 or the FSA Health Care Enrollment form for the PPO on page 14. Anyone interested in enrolling in the Dependent Care FSA will also need to complete an enrollment form on page 14. As a reminder, elections to the FSA Health or Dependent Care and to the HSA are no longer on a calendar year but have changed to fiscal year beginning July 1, Therefore, you will need to make your annual election now for the period from July 1, 2014 to June 30, 2015 at this time. There will be no annual enrollment in January. If you have questions or are interested in enrolling, changing, or canceling coverage in the medical, dental or vision plans, please stop by or call the HR office at ext to request the necessary enrollment/change forms. As a reminder, please return your forms to the HR office by May 1,

3 Medical Insurance Who is Eligible: All full-time employees and dependents to age 26 are eligible to receive Medical & Prescription Drug benefits through the Allegheny College Highmark Plans. Medical & RX Benefits You Receive: Allegheny College offers medical and prescription drug insurance coverage to you and your eligible dependents. Two options will be offered for July 1, 2014 to June 30, 2015 plan year. All employees have the option to enroll in either of the offered plans. Below are brief overviews of the medical and prescription drug plans, for more detailed information on each plan and its provisions, please see pages Highmark PPO In-Network Out-of-Network Deductible Coinsurance Out-of-Pocket Maximum Office Visit Copays Emergency Services $500 single $1,000 family 10% $1,000 single $2,000 family $20 Primary Care $30 Specialist $1,000 single $2,000 family 30% $3,000 single $6,000 family 30% after deductible $100 Copay (waived if admitted) Urgent Care Copay $30 X-Ray and Laboratory Services 10% after deductible 30% after deductible Mental Health & Substance Abuse Services Inpatient: 10% after deductible Outpatient: $10 copay/visit 30% after deductible 30% after deductible Prescription Drug Coverage: Retail Copayments (31 day supply) Mail Order Copayments (90 day supply) $10/$35/$70 $20/$70/$140 3

4 Highmark Qualified High Deductible Health Plan (HDHP) Deductible Coinsurance Out-of-Pocket Maximum In-Network 10% $1,500 single $3,000 family $1,500 single $3,000 family Out-of-Network 30% $3,000 single $6,000 family Office Visit 10% after deductible 30% after deductible Emergency Services 10% after deductible 30% after deductible Urgent Care 10% after deductible 30% after deductible X-Ray and Laboratory Services 10% after deductible 30% after deductible Mental Health & Substance Abuse Services 10% after deductible 30% after deductible Prescription Drug Coverage 10% after deductible, deductible combined with medical Health Savings Accounts (HSA) Who is Eligible: Any Allegheny College employee who elects the Qualified High Deductible Health Plan is eligible to open an HSA account as long as you: are not covered by other health insurance, not enrolled in any type of Medicare (including Part A) or Tricare, and can t be claimed as a dependent on someone else s tax return. As a reminder, dependent children must be considered a tax-qualified dependent in order to receive medical reimbursements under the HSA. Benefits You Receive: If you elect to have contributions deducted pre-tax through payroll, in addition to the $750 individual and $1,500 individual + dependents that the College will be depositing on a semi-annual basis, please complete the Pre-Tax Health Savings Account (HSA) Election Form on page12. The maximum amount that can be contributed (and deducted) to a Health Savings Account in 2014 from all sources is $3,300 for individual coverage and $6,550 for family coverage. Remember, if you are 55+ you can add an additional $1,000 to your contribution. If you should decide to use any other banking institution besides Bank of America (Highmark s preferred vendor), you must complete the bottom portion of the Pre-Tax Health Savings Account (HSA) Election Form. If you elect the Qualified High Deductible Health Plan, more information regarding the Health Savings Account will be provided to you in mid-may, early to mid-july and late September. 4

5 Voluntary Dental Insurance Who is Eligible and When: All full-time employees and dependents to age 26 are eligible to receive Dental benefits through the Allegheny College United Concordia Plan. The chart below shows a high level overview on how each type of service is covered. For more detailed information see page 23. Type of Service Deductible (applies to Basic & Major services only) Annual Benefit Coverage Amount $50/person or $150/family (does not apply to preventive services) $1,000 per person Preventive Services 100% Basic Services 80% Major Services 50% Voluntary Vision Who is Eligible and When: All full-time employees are eligible to receive Vision benefits through the Allegheny College Vision Benefits of America (VBA) plan. For more detailed information see page Benefits You Receive: Eye or Contact Exams Every 12 months Lenses (Eye Glasses or contacts) Every 12 months Frames Every 24 months Contacts covered up to $160 (includes vision exam allowance) 5

6 Flexible Spending Accounts (FSA) You can elect a Health Care FSA account or a Dependent Care Account, or both (Dependent Care FSA is only for child care or elder expenses) if enrolled in the PPO Plan. If you elect the Qualified High Deductible Health Plan you CANNOT enroll in the Health Care FSA, but can enroll in the Dependent Care FSA. As a reminder, dependent children must be considered a tax-qualified dependent in order to receive medical reimbursements under the FSA. Benefits You Receive: FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis. By anticipating your family s health care and dependent care costs for the next year, you can actually lower your taxable income. The plan year will now run from July 1 June 30 of each year. The Health Care FSA contains a grace period at the end of every plan year that allows extra time to incur expenses to use remaining any Health Care FSA balances after the close of the plan year. The Grace Period is 2 ½ months long (through September 15th of the following year) As a participant, you have until September 15 of the next plan year to incur claims against your previous year's FSA funds. Only participants who have Health Care FSA coverage through June 30 of the previous plan year can continue to incur claims in the grace period. All Health Care FSA claims for services provided during the grace period will automatically be processed against the previous year's plan year first if filed by the claims filing deadline for that plan year, unless you request otherwise. If your claim exceeds the available funds from the previous plan year, any excess will be automatically applied to the new plan year. Health Care FSA The Health Care FSA is designed to reimburse out-of-pocket health care expenses not reimbursed through any other benefit as well as over-the-counter medications with a prescription from your doctor. You can set aside a maximum of $2,500. Examples of reimbursable expenses include: Hearing services, including hearing aids and batteries Vision services, including contact lenses, contact lens solution, eye examinations and eyeglasses Dental services and orthodontia Chiropractic services Acupuncture Prescription contraceptives Deductible, copays, co-insurance 6

7 Dependent Care FSA The Dependent Care FSA allows employees to use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders. The annual maximum amount you may contribute to the Dependent Care FSA is $5,000 (or $2,500 if married and filing separately) per calendar year. Examples include: The cost of child or adult dependent care The cost for an individual to provide care either in or out of your house Nursery schools and preschools (excluding kindergarten) Long Term Disability Who is Eligible and When: All full-time employees are eligible to receive Long Term Disability (LTD) benefits at no cost to them. Coverage becomes available effective the first day of the month following date of hire. Allegheny College pays 100% of the premium for Long Term Disability benefit. For more information on this benefit please see the detailed benefit booklet. Benefits You Receive: In the event you are deemed disabled and are unable to continue to work, disability income benefits are provided as a source of income. Long Term Disability benefits are offset by other sources of income, including social security benefits. The plan will pay 60% of your monthly income to a maximum benefit of $5,000 per month. There is an elimination period of 180 days before benefits begin. Life and AD&D Insurance Who is Eligible and When: All full-time employees are eligible to receive Basic Life and AD&D benefits at no cost to them. Coverage becomes available effective the first day of the month following date of hire Basic Life & AD&D Insurance Provides full-time employees with 1 ½ times basic annual earnings up to $250,000 life insurance and accidental death and dismemberment (AD&D) insurance. Allegheny College pays the full cost of this benefit. For more information on this benefit please see the detailed benefit booklet. Contact Human Resources to update your beneficiary information. 7

8 Questions & Answers Forms to be completed: Payroll Authorization Form (page 11): All employees must complete, even if waiving coverage or opting out of coverage. Pre-Tax Health Savings Account (HSA) Election Form (page 12): Only if you are enrolling in the Qualified High Deductible Health Plan. Flexible Spending Account (FSA) Election Form (page 14): Only if you are enrolling in the Health and/or Dependent Care Spending Account(s). Do I need to complete forms if I DON T want to make any changes to my current benefits? You only need to complete the applicable forms above; you do NOT need to complete new enrollment forms. What Forms must be completed if I want to make changes to my existing benefits? You must complete the applicable carrier change form (pages 15-18) in order to make changes to your existing coverage(s). If you are currently enrolled in the medical plan and do not return the Payroll Authorization form, the default medical plan assigned to you will be the PPO. When are the forms due and where do I return them? All forms must be returned to Human Resources by May 1, If I choose not to enroll in the medical, dental, or vision group plans during Open Enrollment, may I choose to enroll later? Yes, but only if you experience a Qualifying Life Event such as marriage, divorce, birth of a child. You must contact Human Resources within 30 days of the Life Event. Whom do I contact with questions? Contact Human Resources with any questions you may have The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of If you have any questions about this summary, contact Human Resources. 8

9 Medical PPO Rates effective July 1, 2014 June 30, 2015 Salary Range Medical Type % of Premium Monthly Premium Annual Premium Employee Annual Cost Based on % of Premium Employee Monthly Cost Based on % of Premium Employee BiWeekly Cost Based on % of Premium* Employer Annual Cost 0 - $30, Single 3.5% $ $6, $ $18.52 $9.26 $6, $ $ Single 5.0% $ $6, $ $26.45 $13.23 $6, $ $ Single 10.0% $ $6, $ $52.90 $26.45 $5, $ $ Single 15.0% $ $6, $ $79.36 $39.68 $5, $65000-$ Single 22.5% $ $6, $1, $ $59.52 $4, $90000-$ Single 30.0% $ $6, $1, $ $79.36 $4, $ Single 37.5% $ $6, $2, $ $99.20 $3, $30, Ee+Child(ren) 3.5% $1, $15, $ $44.45 $22.23 $14, $ $ Ee+Child(ren) 5.0% $1, $15, $ $63.50 $31.75 $14, $ $ Ee+Child(ren) 10.0% $1, $15, $1, $ $63.50 $13, $ $ Ee+Child(ren) 15.0% $1, $15, $2, $ $95.25 $12, $65000-$ Ee+Child(ren) 22.5% $1, $15, $3, $ $ $11, $90000-$ Ee+Child(ren) 30.0% $1, $15, $4, $ $ $10, $ Ee+Child(ren) 37.5% $1, $15, $5, $ $ $9, $30, Ee+Spouse/Partner 3.5% $1, $17, $ $49.87 $24.93 $16, $ $ Ee+Spouse/Partner 5.0% $1, $17, $ $71.24 $35.62 $16, $ $ Ee+Spouse/Partner 10.0% $1, $17, $1, $ $71.24 $15, $ $ Ee+Spouse/Partner 15.0% $1, $17, $2, $ $ $14, $65000-$ Ee+Spouse/Partner 22.5% $1, $17, $3, $ $ $13, $90000-$ Ee+Spouse/Partner 30.0% $1, $17, $5, $ $ $11, $ Ee+Spouse/Partner 37.5% $1, $17, $6, $ $ $10, $30, Ee+Family 3.5% $1, $19, $ $57.39 $28.69 $18, $ $ Ee+Family 5.0% $1, $19, $ $81.98 $40.99 $18, $ $ Ee+Family 10.0% $1, $19, $1, $ $81.98 $17, $ $ Ee+Family 15.0% $1, $19, $2, $ $ $16, $65000-$ Ee+Family 22.5% $1, $19, $4, $ $ $15, $90000-$ Ee+Family 30.0% $1, $19, $5, $ $ $13, $ Ee+Family 37.5% $1, $19, $7, $ $ $12, * NOTE: Bi-weekly deductions are over 24 pay periods. 9

10 Medical QHDHP Rates effective July 1, 2014 June 30, 3015 Salary Range Medical Type % of Premium Monthly Premium Annual Premium Employee Annual Cost Based on % of Premium Employee Monthly Cost Based on % of Premium Employee BiWeekly Cost Based on % of Premium* Employer Annual Cost 0 - $30, Single 1.5% $ $5, $82.88 $6.91 $3.45 $5, $ $ Single 2.5% $ $5, $ $11.51 $5.76 $5, $ $ Single 5.0% $ $5, $ $23.02 $11.51 $5, $ $ Single 10.0% $ $5, $ $46.04 $23.02 $4, $65000-$ Single 15.0% $ $5, $ $69.06 $34.53 $4, $90000-$ Single 20.0% $ $5, $1, $92.09 $46.04 $4, $ Single 25.0% $ $5, $1, $ $57.55 $4, $30, Ee+Child(ren) 1.5% $1, $13, $ $16.58 $8.29 $13, $ $ Ee+Child(ren) 2.5% $1, $13, $ $27.63 $13.82 $12, $ $ Ee+Child(ren) 5.0% $1, $13, $ $55.27 $27.63 $12, $ $ Ee+Child(ren) 10.0% $1, $13, $1, $ $55.27 $11, $65000-$ Ee+Child(ren) 15.0% $1, $13, $1, $ $82.90 $11, $90000-$ Ee+Child(ren) 20.0% $1, $13, $2, $ $ $10, $ Ee+Child(ren) 25.0% $1, $13, $3, $ $ $9, $30, Ee+Spouse/Partner 1.5% $1, $14, $ $18.60 $9.30 $14, $ $ Ee+Spouse/Partner 2.5% $1, $14, $ $31.00 $15.50 $14, $ $ Ee+Spouse/Partner 5.0% $1, $14, $ $62.00 $31.00 $14, $ $ Ee+Spouse/Partner 10.0% $1, $14, $1, $ $62.00 $13, $65000-$ Ee+Spouse/Partner 15.0% $1, $14, $2, $ $93.00 $12, $90000-$ Ee+Spouse/Partner 20.0% $1, $14, $2, $ $ $11, $ Ee+Spouse/Partner 25.0% $1, $14, $3, $ $ $11, $30, Ee+Family 1.5% $1, $17, $ $21.40 $10.70 $16, $ $ Ee+Family 2.5% $1, $17, $ $35.67 $17.84 $16, $ $ Ee+Family 5.0% $1, $17, $ $71.35 $35.67 $16, $ $ Ee+Family 10.0% $1, $17, $1, $ $71.35 $15, $65000-$ Ee+Family 15.0% $1, $17, $2, $ $ $14, $90000-$ Ee+Family 20.0% $1, $17, $3, $ $ $13, $ Ee+Family 25.0% $1, $17, $4, $ $ $12, * NOTE: Bi-weekly deductions are over 24 pay periods. 10

11 Allegheny College Payroll Authorization Form Medical Coverage Effective July 1, 2014 Name: Social Security Number: Marital Status: Single Married Partner # of Dependents Elect or Change Coverage OR Cancel/Waive Coverage (check plan & classification below) Highmark PPO Option Single* Employee & Child(ren)* Employee & Spouse/Partner* Family* Highmark Qualified High Deductible Option Single* Employee & Child(ren)* Employee & Spouse/Partner* Family* *The cost to the employee for the medical coverage will be at a percent of premium based on the attached schedule. Salary Reduction Agreement (check appropriate arrangement): By checking this line, I authorize Allegheny College to reduce my future earnings on a pre-tax basis, effective. By checking this line, I authorize Allegheny College to reduce my future earnings on a post-tax basis, effective. If my dependents or I have a change in family or employment status, I may be able to change the choices made by completing a new enrollment form and payroll authorization form within 30 days of the date of the status change. I also understand that adding dependents to the coverage at a later date other than as a result of a change in family status (late enrollment) will require that I will be subject to the underwriting requirements of the carrier before the coverage can be provided, and the coverage can only be effective as of the next July 1 st. Signature: Date: Rev.3/14 11

12 **COMPLETE ONLY IF YOU HAVE ELECTED THE HIGH DEDUCTIBLE HEALTH PLAN** Allegheny College Pre-Tax Health Savings Account (HSA) Election Form This form enables you to elect to have a Federal pre-tax payroll deduction into your Health Savings Account (HSA) for those that enroll in the Qualified High Deductible Health Plan option. There are contribution limits that are set each calendar year by tax law, so check with Human Resources if you have any questions about these limits. This form is to elect what amount you would like to contribute to your HSA above and beyond the $750 individual coverage and $1,500 for individual + dependents. In addition to what the College contribution, you can contribution as well. Complete 1 or 2 below: 1. Yes, I want a payroll deduction in addition to the College contribution into my HSA as noted below. - Complete both the Amount Per Paycheck AND Amount per Year below. $ x 12 or 26 = $ Amount Per Paycheck Number of Paychecks Amount per Year 2. No, I DO NOT want a payroll deduction in addition to the College contribution into my HSA, as noted below. Employee PRINTED Name: Employee Signature: Date: If you are using another bank for your Health Savings Account, please include the Account and Routing Number below. Contributions will NOT be deposited until this portion is completed. Bank Name Routing Number Account Number After you have completed this form, submit to Human Resources 12

13 Allegheny College Payroll Authorization Form - Dental/Vision Coverage Rates Effective July 1, 2014 Name: Social Security Number: Marital Status: Single Married Partner # of Dependents Dental Plan (check plan and classification): Per Pay Contribution Level Elect/Change Coverage (check classification below also) Single Employee & Spouse/Partner Employee & Child Employee & Children Family Cancel Coverage Paid Bi-Weekly $ Paid Monthly $ Vision Plan (check plan and classification): Per Pay Contribution Level Elect/Change Coverage (check classification below also) Single Employee & Spouse/Partner Employee & Child Employee & Children Family Cancel Coverage Paid Bi-Weekly $ Paid Monthly $ Salary Reduction Agreement (check appropriate arrangement): By checking this line, I authorize Allegheny College to reduce my future earnings by the contribution level chosen above on a pre-tax basis. By checking this line, I authorize Allegheny College to reduce my future earnings by the contribution level chosen above on a post-tax basis. I understand that the choices made for vision coverage will remain in effect for at least two years. If I have a change in family or employment status, I may be able to change the choices made by completing a new payroll authorization form within 30 days of the date of the status change. I also understand that adding dependents to the coverage at a later date other than as a result of a change in family status (late enrollment) will require that I will be subject to the underwriting requirements of the carrier before the coverage can be provided. Signature: Date: 13

14 14

15 15

16 DENTAL ENROLLMENT FORM For New Enrollment, please complete ALL sections of this form. For Enrollment Changes, please complete the applicable Type of Activity change(s) in Section A along with the identification number and employee name in Section B and Section C for dependent changes. SECTION A: GENERAL INFORMATION 1. TYPE OF PROGRAM FFS (Indemnity, Active PPO, Passive PPO - Please Specify) Concordia Access Concordia Choice Concordia Flex Concordia Preferred Concordia Select Other DHMO (Please Specify) Concordia Plus Other 2. TYPE OF ACTIVITY New Enrollment Cancel Coverage Cancel All Coverage (Employee & All Dependents) Cancel Dependent(s) Only (List dependents to be cancelled) Change (Please Specify) Add Dependent (e.g., spouse, domestic partner, child, etc.) Change Address Reinstate Coverage Change Name Change Group Number Change Provider COBRA Other Effective Date (mm/dd/yyyy) / / SECTION E: FOR EMPLOYER USE ONLY EMPLOYER INFORMATION Employer Name Group Number Sub Group UCCI Payroll Location SECTION B: EMPLOYEE INFORMATION - Please print clearly to expedite your request. 1. Identification Number ( For example, Social Security Number) 2. Original Employment Date (mm/dd/yyyy) / / 3. Employee Name ( Last, First, Middle Initial ) 4. Date of Birth 5. Sex 6. Provider Number (DHMO Only) 7. Home Address City State Zip Code SECTION C: DEPENDENT INFORMATION Please list the added/cancelled dependents in this section. For more than five dependent children, complete and attach an additional form. If dependent children listed in this section are disabled or full-time students age 19 or over, please see your group administrator for a Dependent Certification Form, which should be completed and returned with the Dental Enrollment Form. 1. Identification Number (For example, Social Security Number) 2. Type 3. Last Name 4. First Name 5. MI 6. Sex 7. Date of xxbirt h Spouse/Domestic Partner Dependent (A) 8. Provider Number x x(dhmo Only) Dependent (B) Dependent (C) Dependent (D) Dependent (E) SECTION D: OTHER DENTAL COVERAGE Do you or your dependent(s) have other Group Dental Coverage? If your answer is yes, please complete the following information. Yes No Policy Holder Insurance Company P olicy/identification Number E ffective Date ( mm/dd/yyyy) / / I represent that all information supplied in this application is true and correct. Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime. Employee Signature Date Employer Signature Phone Number Date 5000 (07/05) WEB

17 PROGRAM AVAILABILITY Products are not available in any state where prohibited by law or where United Concordia does not have regulatory approval. Domestic partner coverage is not permitted in Idaho. CA: FL: STATE MANDATED PROVISIONS California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. AZ, All statements made by a Policyholder or by any Insured Member GA, shall be deemed representations and not warranties, and no statements made for the purpose of effecting coverage shall void KY,NE such coverage or reduce benefits unless contained in writing and & NH: signed by the Policyholder. KS: Any person who knowingly and with intent to defraud, as stated on this Application, may be committing a fraudulent insurance act which may be a crime. LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NJ: All statements made by applicant are true and complete to the best of the applicant s knowledge and belief. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OR: Any person who knowingly and with intent to defraud, as stated on this Application, may be committing a fraudulent insurance act which may be a crime. OR: Contestability is limited to two years as stated in the Group Policy. TN: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. UT: Any matter in dispute between you and the company may be subject to arbitration as an alternative to court action pursuant to the Rules of (the American Arbitration Association or other recognized arbitrator), a copy of which is available on request from the company. Any decision reached by arbitration shall be binding upon both you and the company. The arbitration award may include attorney s fees if allowed by state law and may be entered as a judgement in any court of proper jurisdiction. VA: Any person who within the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. UNITED CONCORDIA OPERATES AS A WHOLLY OWNED SUBSIDIARY UNDER THE NAME LISTED BELOW IN THE FOLLOWING STATES: United Concordia Dental Corporation of Alabama AL United Concordia Dental Plans, Inc. MD, NJ United Concordia Dental Plans of California, Inc. CA United Concordia Dental Plans of Delaware, Inc. DE, DC United Concordia Dental Plans of Florida, Inc. FL United Concordia Dental Plans of Kentucky, Inc. KY United Concordia Dental Plans of the Midwest, Inc. MI, MO, OH United Concordia Dental Plans of Pennsylvania, Inc. PA United Concordia Dental Plans of Texas, Inc. TX United Concordia Insurance Company AK, AR, AZ, CA, CO, CT, FL, GA, IA, ID, IN, KS, LA, MA, MD, ME, MI, MN, MS, MT, NE, NH, NV, NM, ND, OH, OK, OR, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WY United Concordia Life and Health Insurance Company DE, DC, IL, KY, MD, MO, NC, NJ, PA United Concordia Insurance Company of New York NY 17

18 VISION BENEFITS OF AMERICA VBA# 1035 SUBGROUP# ENROLLMENT FORM COVERAGE EFFECTIVE DATE / / INSTRUCTIONS FOR EMPLOYEE: 1. COMPLETE SECTION BELOW AND SIGN. 2. RETURN COMPLETED FORM TO YOUR BENEFITS OFFICE. EMPLOYEE SOCIAL SECURITY NUMBER EMPLOYEE NAME BIRTHDATE ADDRESS CITY STATE ZIP CODE - PLEASE LIST ALL FAMILY MEMBERS TO BE COVERED: FIRST NAME MIDDLE INITIAL LAST NAME BIRTHDATE SPOUSE/PARTNER CHILD CHILD CHILD CHILD STUDENT INFORMATION (COMPLETE FOR DEPENDENTS WHO ARE ENROLLED AS FULL-TIME COLLEGE STUDENTS.) STUDENTS NAME NAME OF SCHOOL OR UNIVERSITY ANY HANDICAPPED CHILD COVERED ON MEDICAL? CHILD NAME EMPLOYEE SIGNATURE DATE / / 18

19 Summary of PPO Blue Benefits On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital. Allegheny College Benefit Network Out-of-Network General Provisions Benefit Period(1) Contract Year Deductible (per benefit period) Individual Family $500 $1,000 $1,000 $2,000 Plan Pays payment based on the plan allowance 90% after deductible 70% after deductible Out-of-Pocket Maximums (Once met, plan pays 100% for the rest of the benefit period) Individual Family $1,000 $2,000 $2,000 $4,000 Total Maximum Out of Pocket (7) (Includes deductible, coinsurance, copays and other qualified medical expenses, Network only)(7) Once met, plan pays 100% of covered services for the rest of the benefit period. Individual $6,350 Family $12,700 Not applicable Lifetime Maximums Unlimited, except as notated below Autism Spectrum Disorders (ASD) Maximum (per 90% after deductible 70% after deductible person)(2) Office/Clinic/Urgent Care Visits Retail Clinic Visits 100% after $30 copayment 70% after deductible Primary Care Provider Office Visits 100% after $20 copayment 70% after deductible Specialist Office Visits 100% after $30 copayment 70% after deductible Urgent Care Center Visits / Retail Clinic Visits 100% after $30 copayment 70% after deductible Preventive Care(3) Routine Adult Physical exams 100% (deductible does not apply) Not Covered Adult immunizations 100% (deductible does not apply) 70% after deductible Colorectal cancer screening 100% (deductible does not apply) 70% after deductible Routine gynecological exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply) Mammograms, annual routine and medically necessary Routine: 100% 70% after deductible (deductible does not apply) Medically Necessary: 90% after deductible Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible Routine Pediatric Physical exams 100% (deductible does not apply) Not Covered Pediatric immunizations 100% (deductible does not apply) 70% (deductible does not apply) Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient Hospital Outpatient Maternity (non-preventive facility & professional services) Medical/Surgical (except office visits) 90% after deductible 70% after deductible Emergency Services Emergency Room Services 100% after $100 copayment (waived if admitted) Ambulance 90% after deductible Therapy and Rehabilitation Services Physical Medicine 100% after $10 copayment 70% after deductible Respiratory Therapy 90% after deductible Speech & Occupational Therapy 100% after $10 copayment 70% after deductible Spinal Manipulations 100% after $20 copayment 70% after deductible Limit: 20 visits per calendar year 19

20 Benefit Network Out-of-Network Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis) 90% after deductible 70% after deductible Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation 90% after deductible 70% after deductible Outpatient 100% after $10 copayment 70% after deductible Other Services Allergy Extracts and Injections Applied Behavior Analysis for Autism Spectrum Disorders(2) Assisted Fertilization Procedures(4) 90% after deductible 90% after deductible 70% after deductible 70% after deductible Dental Services Related to Accidental Injury 90% after deductible 70% after deductible Diabetes Treatment 90% after deductible 70% after deductible Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 90% after deductible 70% after deductible Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) 90% after deductible 70% after deductible Durable Medical Equipment, Orthotics and Prosthetics Home Health Care Hospice Infertility Counseling, Testing and Treatment(4) 90% after deductible 70% after deductible Home Infusion Therapy 90% after deductible Private Duty Nursing Enteral Formulae 90% after deductible 70% (deductible does not apply) Skilled Nursing Facility Care 90% after deductible 70% after deductible Transplant Services 90% after deductible 70% after deductible Pre-Existing Condition Clause No Precertification Requirements(5) Yes Prescription Drugs Prescription Drug Deductible Individual Family None None Prescription Drug Program(6) Mandatory Generic Defined by the Premier 2012 Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered. Your plan uses the Comprehensive Formulary. Retail Drugs (34-day Supply) $10 generic copayment $35 formulary brand copayment $70 non-formulary brand copayment Maintenance Drugs through Mail Order (90-day Supply) $20 generic copayment $70 formulary brand copayment $140 non-formulary brand copayment (1) Your group's benefit period is based on a Calendar Year which runs from July 1 to June 30. (2) Coverage for eligible members to age 21. Services will be paid according to the benefit category (e.g. speech therapy). Treatment for autism spectrum disorders does not reduce visit/day limits. (3) Services are limited to those listed on the Highmark Preventive Schedule. Gender, age and frequency limits may apply. (4) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group s prescription drug program. Excludes coverage for services related to in-vitro fertilization and artificial insemination. (5) Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered. (6) The formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. It includes products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above. You are responsible for the payment differential when a generic drug is authorized by your provider and you purchase a brand name drug. Your payment is the price difference between the brand name drug and generic drug in addition to the brand name drug copayment or coinsurance amounts, which may apply. (7) Effective with plan years beginning on or after January 1, 2014 the Network Total Maximum Out-of-Pocket as mandated by the federal government must include deductible, coinsurance, copays, and any qualified medical expenses. The Total Maximum Out of Pocket cannot be more than $6,350 for individual and $12,700 for two or more persons. This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available under your program. Effective 07/01/14 Allegheny College , 01, 60, 70 20

21 Allegheny College - HDHP This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings Account (HSA). On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital. If you enroll as an individual, the deductible and out-of-pocket maximums for the Employee Only Plan apply. If you enroll as a family, the deductible and out-of -pocket maximums for the Family Plan apply and can be satisfied by one or more of your family members. Benefit Network Out-of-Network Benefit Period(1) General Provisions Contract Year Deductible per benefit period (Applies to Medical and Prescription Drug benefits) Employee Only Plan Family Plan $1,500 Combined $3,000 Combined Plan Pays payment based on the plan allowance 90% after deductible 70% after deductible Out-of-Pocket Maximums (Includes prescription drug expenses, coinsurance and copayments. Once met, plan pays 100% for the rest of the benefit period) Employee Only Plan Family Plan $1,500 $3,000 $3,000 $6,000 Total Maximum Out of Pocket (6) Includes deductible and coinsurance and other qualified medical expenses, network only. Once met, plan pays 100% of covered services for the rest of the benefit period. Individual Family $3,000 $6,000 Not applicable Office/Clinic/Urgent Care Visits Retail Clinic Visits 90% after deductible 70% after deductible Primary Care Provider Office Visits 90% after deductible 70% after deductible Specialist Office Visits 90% after deductible 70% after deductible Urgent Care Center Visits 90% after deductible 70% after deductible Preventive Care(2) Routine Adult Physical exams 100% (deductible does not apply) Not Covered Adult immunizations 100% (deductible does not apply) 70% after deductible Colorectal cancer screening 100% (deductible does not apply) 70% after deductible Routine gynecological exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply) Mammograms, annual routine and medically necessary Routine: 100% 70% after deductible (deductible does not apply) Medically Necessary: 90% after deductible Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible Routine Pediatric Physical exams 100% (deductible does not apply) Not Covered Pediatric immunizations 100% (deductible does not apply) 70% (deductible does not apply) Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient Hospital Outpatient Maternity (non-preventive facility & professional services) Medical/Surgical (except office visits) 90% after deductible 70% after deductible Emergency Services Emergency Room Services 90% after deductible Ambulance 90% after deductible Therapy and Rehabilitation Services Physical Medicine 90% after deductible 70% after deductible Respiratory Therapy 90% after deductible 21

22 Benefit Network Out-of-Network Speech & Occupational Therapy 90% after deductible 70% after deductible Spinal Manipulations 90% after deductible 70% after deductible Limit: 20 visits/benefit period Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis) 90% after deductible 70% after deductible Mental Health/Substance Abuse Inpatient Inpatient Detoxification/Rehabilitation 90% after deductible 70% after deductible Outpatient 90% after deductible 70% after deductible Other Services Allergy Extracts and Injections 90% after deductible 70% after deductible Assisted Fertilization Procedures Not Covered Dental Services Related to Accidental Injury 90% after deductible 70% after deductible Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 90% after deductible 70% after deductible Basic Diagnostic Services (standard imaging, diagnostic 90% after deductible 70% after deductible medical, lab/pathology, allergy testing) Durable Medical Equipment, Orthotics and Prosthetics Home Health Care Hospice Infertility Counseling, Testing and Treatment(3) 90% after deductible 70% after deductible Private Duty Nursing 90% after deductible Skilled Nursing Facility Care 90% after deductible 70% after deductible Limit: 100 days/benefit period Transplant Services 90% after deductible 70% after deductible Precertification Requirements(4) Yes Prescription Drugs Prescription Drug Deductible Individual Family Integrated with medical deductible Integrated with medical deductible Prescription Drug Program(5) Defined by the Premier 2012 Pharmacy Network - Not Physician Retail Drugs (31-day Supply) Plan pays 90% after deductible Network. Prescriptions filled at a non-network pharmacy are not covered. Maintenance Drugs through Mail Order (90-day Supply) Plan pays 90% after deductible Your plan uses the Comprehensive Formulary. (1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact your employer to determine the effective date applicable to your program. (2) Services are limited to those listed on the Highmark Preventive Schedule. Gender, age and frequency limits may apply. (3) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group s prescription drug program. (4) Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered. (5) At a retail or mail order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member responsibility based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled. (6) Effective with plan years beginning on or after January 1, 2014 the Network Total Maximum Out-of-Pocket as mandated by the federal government must include deductible, coinsurance, and any qualified medical expenses. This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available under your program. 02/20/2014- Allegheny College QHDHP _ 22

23 Dental Benefits Summary for Allegheny College Effective Date: July 1, 2014 Network: Concordia Advantage Benefit Category 1 Class I Diagnostic/Preventive Services (Excluded from Annual Program Maximum) Exams Bitewing X-rays Cleanings & Fluoride Treatments (includes 1 additional cleaning during pregnancy) Class II Basic Services All Other X-rays Sealants Basic Restorative (Fillings) Simple Extractions Space Maintainers Palliative Treatment Class III Major Services Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures) Endodontics Complex Oral Surgery General Anesthesia Nonsurgical Periodontics Surgical Periodontics Orthodontics for dependent children to age 19 CONCORDIA FLEX In-Network 2 Non-Network 2 Deductible 100% 100% None 80% 80% $50 50% 50% $50 Diagnostic, Active, Retention Treatment Not Covered Not Covered Not Applicable Maximums & Deductibles (cumulative of network and non-network) Annual Program Maximum (per person) $1,000 Excludes Class I Annual Program Deductible (per person/per family) $50/$150 Excludes Class I $1,000 Excludes Class I $50/$150 Excludes Class I Lifetime Orthodontic Maximum (per person) Not Applicable Not Applicable Representative listing of covered services certificate of coverage provides a detailed description of benefits. 1. Dependent children covered to age Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee. United Concordia Dental s standard exclusions and limitations apply FlexC_

24 ALLEGHENY COLLEGE VBA# 1035 MANAGED VISION CARE PROGRAM ZERO COPAYMENT PROGRAM FREQUENCY OF SERVICE: DEPENDENT AGE: 26 Employee Spouse Children Vision Exam 12 Months 12 Months 12 Months Lenses 12 Months 12 Months 12 Months Frames 24 Months 24 Months 24 Months BENEFITS: EMPLOYEE CAN SELECT EITHER: VBA Participating Doctor O (15,000 Nationwide) R Non-Participating Doctor Amount Covered Amount Reimbursed Vision Exam (for glasses) 100% $ Clear Standard Lenses (Pair): Single Vision 100% $ Bifocal 100% Blended No-Line Bifocals 100% Trifocal 100% Lenticular 100% Progressive Controlled Cost**** yr Scratch Protection 100% N/A Polycarbonate Lens Material*** 100% N/A Frame 100%* $ OR - Contacts (selected in lieu of all eyeglass benefits listed above)***** Elective $ $ Medically Required UCR** Low Vision Aids (per 24. mths. No lifetime Max) UCR** * Within the program's $50 wholesale allowance (approximately $125 to $150 retail). ** Usual, Customary and Reasonable as determined by VBA. *** Available In-Network at no charge for children under age 19. **** Clear Progressive Lenses typically retail from $150 to $400, depending on the brand. VBA s controlled costs generally range from $45 to $175. ***** The contact allowance is applied to all services/materials associated with contact lenses. This includes, but not limited to, contact exam, fitting, dispensing, cost of lenses, etc. No guarantee the contact allowance will cover entire contact costs (materials/services). 13\ 24

25 LIMITATIONS Vision Benefits of America is designed to cover visual needs rather than cosmetic materials, and consequently includes some limitations in order to control costs. The following options or services will generally result in additional charges to the patient or are not covered under the plan. ADDITIONAL CHARGES A patient selecting any of the following items will be responsible for the additional charges, all of which are monitored and controlled by VBA. -- Tinted Lenses -- Photochromic/Polarized lenses -- Polycarbonate (covered under age 19) -- Hi-Index lenses -- Progressive (available starting at $45) -- The coating of the lens or lenses (except 1-Yr Scratch Protection) -- A frame that costs more than the plan allowance -- Rimless frames -- Anti-Reflective/Backside UV/Optifog Additionally, costs for contact lenses/services in excess of the plan s scheduled reimbursement allowances are the responsibility of the patient. NOT COVERED The contract gives VBA the right to waive any of the plan limitations if, in the opinion of our optometric consultants, it is necessary for the patient's welfare. VBA provides no benefit for professional services or materials connected with the following: -- Orthoptics or vision training -- Non-prescription lenses -- Two pair of glasses in lieu of bifocals -- Medical or surgical treatment of the eyes -- Any eye examination, or corrective eyewear, required by an employer as a condition of employment -- Services or materials provided as a result of any Workers' Compensation Law or similar legislation -- Glasses and contacts during the same eligibility period Lenses and frames furnished under this program which are lost or broken will not be replaced except at the normal intervals when services are otherwise available. 13\ 25